Episode 086: Prostate Cancer Series: Pt. 3- Surgical Approaches to Prostate Cancer
In our next episode, we are joined by Dr. Sanjay Patel, a urologic oncologist from the Stephenson Cancer Center at the University of Oklahoma, who also happens to be Vivek’s older brother! We discuss the management of prostate cancer from the perspective of our urology colleagues. As medical oncologists, these are conversations and decisions that we are almost never a part of, as they are being had often before patients ever see us. It was so helpful to get to hear how Dr. Patel thinks about his patients!
When patients with elevated PSA are referred to Urology, what are your next steps during the initial evaluation and what would lead you down the path for biopsy?
Most critical to have shared decision-making as part of this process.
Dr. Patel considers many risk factors when assessing patients and providing recommendations. These risk factor include:
Age
Life expectancy
Race (Prostate cancer is more common in Black patients)
Family history of prostate cancer
Family history of other cancers
Also, what is the role of MRI at this point in your workup?
Since prostate MRIs are becoming more readily available, they are becoming the standard of care in the present day.
Prostate MRI findings are reported as “PI-RADS”
Scored on a scale from 1-5
PI-RADS 1 – Very low (clinically significant cancer is highly unlikely to be present)
PI-RADS 2 – Low (clinically significant cancer is unlikely to be present)
PI-RADS 3 – Intermediate (the presence of clinically significant cancer is equivocal)
PI-RADS 4 – High (clinically significant cancer is likely to be present)
PI-RADS 5 – Very high (clinically significant cancer is highly likely to be present)
PI-RADS 4-5 are most worrisome!
Can you walk us through the steps for biopsy in these patients and the rationale for obtaining 12 cores?
The use of 12-core biopsy provides a systematic approach to the prostate biopsy:
Prostate is divided in half and then samples are taken, with a focus on the peripheral sides on the back of the prostate
Use of MRI has helped this:
If there is a lesion seen, then in addition to taking standard 12 biopsies, additional 2-3 biopsies can be taken of the area of concern
If no lesion is seen, but high pre-test probability, this does NOT mean that the person does not have prostate cancer in which case the standard 12-cores should still be taken.
MRI has also made sampling more precise through two ways:
Fusion Biopsy: A computer program fuses the MRI and the ultrasound images on the probe and provides guidance about how to move the needle when doing the biopsy
Cognitive fusion biopsy: Use the MRI to find the image and then use the ultrasound to locate the image; but the images are not superimposed
Another change is that most biopsies are no longer done trans-rectally. Now many are done in the OR under sedation via a trans-perineal route, which decreases the risk of infection, improves the patient experience, and can have a better yield.
When you get a patient that is intermediate risk, how do you proceed with staging imaging? Do you prefer PSMA PET/CT and do you get it on all intermediate risk or just unfavorable intermediate in your practice?
If favorable risk: no further imaging is needed
If unfavorable risk: imaging is indicated
The old recommendations would suggest getting bone imaging and cross-sectional imaging
With the advent of PSMA-PET scan, they can look at bone and visceral organs
For our patient with unfavorable intermediate risk, the NCCN recommends that something happens and active surveillance isn’t an option. How do you counsel these patients on treatment options and risk benefits of surgery vs. radiation?
This is also an individualize discussion that relies on shared decision-making. Factors that are considered:
How well can this person tolerate surgery?
Are they a poor surgical candidate with history including prior abdominal surgeries, cardiopulmonary disease?
Is the patient having “urinary symptoms”?
Issues with urgency: radiation is going to likely make this worse
Obstructive symptoms (enlarged prostate, dribbling): surgery may be better as it can help fix this problem too
Personal preferences: Does the person have concerns about undergoing a surgical procedure?
Using MRI to help determine if there’s any higher risk features (location, extraprostatic extension, etc.)
Quality of life concerns:
Urinary incontinence: relatively common after prostatectomy. Better with robotic procedures, but can still happen.
Patients will need to do kegel exercises after surgery
They may need to wear pads or adult briefs
Urinary incontinence does not happen with radiation, but radiation increases irritation.
Erectile dysfunction: Even with very experiences surgeon, ED is likely to happen.
After surgery, it will almost be immediate
After radiation, it may take a few years to set in
Eventually, both groups have about same rates of ED
Timing:
Having a surgery is 3-4 hours followed by maybe 12-24 hours of observation
Radiation may require going to a radiation center 5 days a week for 6-8 weeks depending on the fractionation. Is this feasible for the patient?
Is the patient someone who likely “numbers”?:
After surgery, PSA should be zero. A rise in PSA from undetectable levels would be of concern.
After radiation, each person nadirs to a different number and then a biochemical recurrence would be defined as a rise in the PSA by 2 points.
Future plans:
Surgery after radiation is a lot harder due to scarring, which can lead to poor healing and incidence of ED
happens immediately after surgery; radiation can be delayed onset. Some elements of ED. Later on, it’s about the same incidence of ED
Timing: surgery is done in a few hours and requiring minimal time in the hospital; radiation is going to be 5 days a week for 6-8 weeks depending on the fractionation
Numbers: Undetectable after prostatectomy, some people want that reassurance; after radiation, it will go to a nadir – nadir + 2 is recurrence
Radiation first makes surgery later harder - increased risk of poor healing, more incidence of ED
When do you proceed with a pelvic lymph node dissection?
Most surgeons now use a risk-adapted approach. Institutions such as Memorial Sloan Kettering have developed models (example: https://www.mskcc.org/nomograms/prostate/pre_op)
In patients with >2% risk of nodal involvement, pelvic lymph node dissection is recommended
Why not just remove the pelvic lymph nodes on everyone?
Nodes are on external iliac artery; most of the time, people don’t have morbidity from it
Damage to external iliac artery or vein is possible (small percentage)
Obturator nerve (ADduction) can have injury (small percentage)
Lymphocele can develop that can become enlarged and painful or infection (~2-3% of the time)
Lymphedema
What is “active surveillance”?
Acceptable in patients with lower risk prostate cancer (See Episode 083)
Ultimately, this is also going to be shared decision-making
Dr. Patel’s approach:
Confirmatory biopsy in 6-12 months to ensure that the patient is truly lower risk
Following PSA every 6 months
MRI a few years (~3 years) down the road to ensure stability
MRI allows us to also watch an area of concern for growth if there was one on the baseline scan
He also repeats biopsies a few years later, too
Yearly biopsies are not done as much anymore given the advent of MRI
If anything changes (new symptoms, PSA rise), investigate earlier
What about in patients with high risk and very high risk disease localized prostate cancer - which patients are you referring to radiation?
In general, if there is evidence of extraprostatic extension or local invasion, then radiation is going to be better than surgery
In high risk patients, treatment with radiation + ADT is going to be better
If really very high risk features + radiation + ADT + abiraterone/pred is preferred
If there is nodal positive on imaging, would you still proceed with surgery?
Individualized approach can take place and there is going to be some differences based on surgeon expertise, experience, and gestalt
About our guest: Sanjay Patel, MD is a Urologic Oncologist and assistant professor of Urology at the University of Oklahoma College of Medicine and at OU Health Stephenson Cancer Center. He completed medical school at Vanderbilt University Medical Center, where he also completed his residency in urology. He subsequently completed his fellowship in urologic oncology at the University of Chicago Medical Center.
The crew behind the magic:
Show outline: Vivek Patel
Production and hosts: Ronak Mistry, Vivek Patel, Dan Hausrath
Editing: Resonate Recordings
Shownotes: Ronak Mistry
Social media management: Ronak Mistry
We are proud to partner with HemOnc.org!
Want to learn more about the trials that lead to the regimens discussed today? What about dosing schedules? See links in the show notes for a link to HemOnc.org
